NU226 Exam I

Question 1

Pt. fall risk factors (#10)

Answer 1

>65yo
Prior fall
Impaired vision
Impaired balance
Gait disturbance
Medications
Postural hypotension
Slowed reaction time
Confusion
Unfamiliar environment

Question 2

Nurse’s reaction to fire alarm (RACE)

Answer 2

Rescue and remove Pts from danger
Activate alarm
Confine fire
Extinguish fire

Question 3

The Four Ps

Reasons Pts may try to leave bed or have problems

Answer 3

Pain
Potty
Position
Presence

Question 4

Systemic effects of immobility on metabolic & GI systems

Answer 4

⬇ ️Metabolic rate, ⬇ appetite, ⬇ ️GI peristalsis, eventual constipation/fecal impaction

Question 5

Systemic effects of immobility on respiratory system

Answer 5

Atelectasis, ⬇ ️effectiveness of cough, ⬇ ️respiratory depth, pooling secretions, eventual pneumonia

Question 6

Systemic effects of immobility on cardiovascular system

Answer 6

Orthodontic hypotension, ⬆️ cardiac workload, eventual thrombus formation

Question 7

Systemic effects of immobility on musculoskeletal system

Answer 7

⬇️ Muscle mass, disuse atrophy, disuse osteoporosis, joint contractures, foot drop

Question 8

DVT

Answer 8

deep vein thrombosis

Question 9

Weight-bearing stages for walking on crutches

Answer 9

1) . Weight bearing as tolerated
2) . Partial weight bearing (50%)
3) . Toe touch weight bearing
4) . Non-weight bearing

Question 10

Systemic effects of immobility on urinary system

Answer 10

Urinary stasis (loss of gravity to drain), ⬆️ risk of UTI & renal calculi, ⬇️ bladder tone

Question 11

Systemic effects of immobility on integumentary system

Answer 11

Pressure ulcer

Question 12

Systemic effects of immobility on psychological health

Answer 12

Sensory deprivation, altered sleep pattern, ⬆️ anxiety/depression

Question 13

ROM

Answer 13

range of motion

1) . Passive: HCP provides motion
2) . Active: Pt provides motion

Question 14

Infection cycle (#6)

Answer 14

Infectious agent
Reservoir
Portal of exit
Means of transmission
Portals of entry
Susceptible host

Question 15

QSEN

Answer 15

Quality and Safety Education for Nurses

Question 16

Endemic

Answer 16

Disease that occurs predictably in a specific region or population.

Question 17

Disease transmission contact routes (#2)

Answer 17

1) . Direct: physical contact between carrier & host

2) . Indirect: contact with a contaminated object (aka “fomite”)

Question 18

Fomite

Answer 18

Inanimate object contaminated with decease agent that can transit through contact

Question 19

Vector

Answer 19

Nonhuman disease carriers (reservoirs) that transmit infection to humans via salivary injection during bite

Question 20

Stages of infection (#4)

Answer 20

1) . Incubation
2) . Prodromal stage
3) . Full stage of illness
4) . Convalescent period